Chondroid syringoma of an upper eyelid tumor: Unusual case report

We present the case report of a 58-year-old man with recurrent chondroid syringoma, which was histopathologically confirmed, who underwent exenteration surgery of the right eye. Furthermore, the patient was receiving postoperative radiation therapy, and presently there is no local and/or distant evidence of disease in the patient.

Stereotactic radiosurgery for recurrent pleomorphic adenoma of the lacrimal gland: a case report

Lacrimal gland pleomorphic adenomas (LGPAs) are common, benign, and intraorbital tumours that cause exophthalmos, ptosis, and visual disturbances. The curative treatment for LGPAs is gross total resection, and radiotherapy is considered adjunctive for recurrence or an alternative for inoperable LGPAs. Stereotactic radiosurgery (SRS) can be used for precise delivery of high radiation doses to the tumour, crucial in the treatment of intra-and extracranial neoplasms. Here, we present a 95-year-old woman who had a rapidly growing, recurrent LGPA and was successfully treated with SRS. The tumour was controlled without any adverse events over 21 months following SRS. SRS is a potential alternative treatment for recurrent LGPA.

Radiotherapy of salivary gland tumours

Primary tumours of the salivary glands account for about 5 to 10% of tumours of the head and neck. These tumours represent a multitude of situations and histologies, where surgery is the mainstay of treatment and radiotherapy is frequently needed for malignant tumours (in case of stage T3-T4, nodal involvement, extraparotid invasion, positive or close resection margins, histological high-grade tumour, lymphovascular or perineural invasion, bone involvement postoperatively, or unresectable tumours). The diagnosis relies on anatomic and functional MRI and ultrasound-guided fine-needle aspiration for the diagnostic of benign or malignant tumors. In addition to patient characteristics, the determination of primary and nodal target volumes depends on tumor extensions and stage, histology and grade. Therefore, radiotherapy of salivary gland tumors requires a certain degree of personalization, which has been codified in the recommendations of the French multidisciplinary network of expertise for rare ENT cancers (Refcor) and may justify a specialised multidisciplinary discussion. Although radiotherapy is usually recommended for malignant tumours only, recurrent pleomorphic adenomas may sometimes require radiotherapy based on multidisciplinary discussion. An update of indications and recommendations for radiotherapy for salivary gland tumours in terms of techniques, doses, target volumes and dose constraints to organs at risk of the French society for radiotherapy and oncology (SFRO) was reported in this article.

Primary Parapharyngeal Space Tumors in a Mexican Cancer Center

OBJECTIVE: To describe clinical and demographic characteristics of the parapharyngeal space tumors and assess surgical approaches used to treat them at our institution.

METHODS: A retrospective and descriptive study of the parapharyngeal space tumors, excluding paragangliomas, treated from June 1991 to October 2002 in a cancer center. The study population included 21 patients, 8 men and 13 women, average age of 41 years (range, 20 to 70 years). Fine needle biopsy was done in 5 (24%) patients. Computed tomography (CT) was performed in all patients, and only a few required magnetic resonance image (MRI).

RESULTS: Surgical approaches included transcervical alone or in combination with parotidectomy, transoral, or transmandibular (mandibular swing) approach. Laminectomy and segmentary approaches were also performed in 1 patient each. Sixteen (76%) patients had benign lesions and 5 (24%) had malignant tumors. Neurogenic tumors represented 57% of all tumors. Mean tumor size was of 6.7 cm (range, 3 to 11 cm). Six (29%) patients received adjuvant radiotherapy. Complications occurred in 6 (29%) patients, 4 (19%) of which were nervous injuries associated with peripheral nerve sheath tumors. Median disease-free follow-up survival was 33 months (range, 2 to 184 months) despite being an heterogeneous group of histologies.

CONCLUSION: Parapharyngeal space is a rare location for head and neck tumors. Cervical approach should be the first choice for large tumors; transoral approach is reserved for tumors less than 3 cm. Conversion to mandibular swing approach when the cervical approach is not offering proper exposure for tumor resection is indicated. Preoperative histologic diagnosis is not required. Nevertheless, CT scan should always be performed in order to exclude paragangliomas, distinguish prestyloid from poststyloid lesions, and to assess the extension of the tumor as well as its relationship with adjacent structures.

Postoperative radiation therapy for parotid pleomorphic adenoma with close or positive margins: treatment outcomes and toxicities

AIM

To evaluate the locoregional control and treatment toxicity of patients with pleomorphic adenoma after resection with close or positive margins followed by postoperative radiation therapy (PORT).

PATIENTS AND METHODS

Between 2002 and 2011, twenty-one patients underwent PORT at the Mount Sinai Beth Israel Medical Center for pleomorphic adenoma of the parotid with close or positive margins. Four out of the 21 patients (19%) had recurrent lesions. The median dose was 57.6 Gy (range 55.8-69.96) delivered at 1.8-2.12 Gy/fraction. Treatment and follow-up data were retrospectively analyzed for locoregional control as well as acute- and late-treatment toxicities. Actuarial survival analysis was also performed.

RESULTS

Twelve women and 9 men with a median age of 46 (26-65) at PORT were included in this study. Eighty-one percent of the cohort had positive resection margins while 19% had close margins. At a median follow-up of 92 months, 19/21 patients (90%) had locoregional control. Two patients who failed had primary lesions which recurred locally, and initially had positive margins. The two recurrences occurred at 8 months and 12 months. Acute Radiation Therapy Oncology Group (RTOG) grade 1 and 2 toxicities were experienced by 11 (52%) and 4 (19%) patients, respectively, while 2 (10%) experienced late RTOG grade 1 toxicities. No patients experienced any grade 2-4 late toxicities. Actuarial survival was 100%.

CONCLUSION

PORT for patients with pleomorphic adenoma of the parotid gland after resection with close or positive margins results in excellent locoregional control and low treatment-related morbidity.

[Recurrent mixed parotid tumor localized in pharyngeal processus]

Tumors of pleomorhic adenoma parapharingeal space of the parotid gland amount for less than 20% of all salivary gland tumors. In most cases these tumors are benign, and pleomorphic (polymorphous) adenomas prevail among them (up to 80-90%). The frequency of their malignization varies from 3.6 to 30%. Pleomorphic adenoma of parapharingeal space of the parotid gland was removed from patient S., aged 23 years, in head and neck department of RROI. Tumors of superficial part of the parotid gland were removed from the patient 5 times during the last 10 years maintaining the integrity of the facial nerve. Each time the tumor was pleomorphic adenoma morphologically. After physical and x-ray (CT, MRI, MRI with angiography of neck vessels) examinations a tumor -- pleomorphic adenoma -- was removed with submandibular method. The control MRI check showed continued growth. Radiation therapy was prescribed, after which the pronounced therapeutic effect was noted. The patient has been observed for 8 months without recurrence.

[Fractionated stereotactic irradiation of skull-base related tumours]

The prognosis of the treatment of brain tumours depends on two main factors: biological nature and localisation of the neoplasm. Requirements of oncologic surgery can be met only partially if at all in neurological surgery of brain tumours. Resectability depends primarily on localisation of the neoplasms. The leading principle is preservation of fine neural structures, minimising morbidity from tissue resection with the goal of maximal tumour resection. As nervous structures and the target volume do not move in the intracranial space, large radiation doses unusual in traditional radiotherapy can be given either in one or in fractionated sessions to small targets (point-radiation) and a well-controlled radiation necrosis of the pathological tissue can be achieved. Management principles of treatment of skull-base related tumours are very similar due to high risks of functional morbidity evoked by surgical injury to the cranial nerves, brainstem structures, vessels of the Willis circle and those of the substantia perforata anterior and posterior, etc. Such tumours are neoplasms arising from the skull base, those infiltrating the cavernous sinuses, invasive pituitary tumours, those arising from the glomus jugulare, or located within the cerebello-pontine angle, etc. This manuscript intends to illustrate and prove the hypothesis by means of 4 cases that fractionated stereotactic radiotherapy (fSRT) is an important part of treatment armamentarium in the latter cases, as it is capable of exploiting both the advantages of traditional fractionated irradiation and that of the high conformality and selectivity of radiosurgery. It is capable of administering appropriate quantity of total target dose with a lower than limit dose on surrounding structures. The presentation proves that fSRT can be planned already in the phase of surgical indication as a "microsurgery-assisted radiotherapy".

Multinodular neck recurrence of parotid gland pleomorphic adenoma: a case report

BACKGROUND

Pleomorphic adenoma is the most common neoplasm of the parotid gland. It is a benign tumor composed of epithelial and myoepithelial cells arranged in various morphological patterns. The most common reasons contributing to a recurrent disease are obvious or underestimated tumor spillage, incomplete excision, and violation of the pseudocapsule of the tumor.

CASE REPORT

This article presents a case of gross multinodular recurrence of a parotid gland pleomorphic adenoma in a 38-year-old female patient. Upon clinical examination of the homolateral neck, multiple, painless, well-defined, palpable, nontender masses and subcutaneous nodules of the right parotid and homolateral neck region were revealed. The patient was treated with surgery and subsequent radiation therapy. Histologic examination of the resected specimen was suggestive of a recurrent pleomorphic adenoma disease. There were no signs of malignant transformation in the specimen. The diagnostic procedure followed, and management of the patient is outlined in the paper.

DISCUSSION

Pleomorphic adenoma is the most common tumor of the parotid gland. In spite of being a benign neoplasm, inadequate management of the lesion may lead to problems such as local recurrence or malignant transformation. Management of recurrent tumors is challenging because the probability of subsequent recurrence increases with each recurrent episode, thus making local control increasingly difficult and damage to the facial nerve more likely.

Parotidectomy in the treatment of pleomorphic adenoma -- analysis of long-term results

CONCLUSION

Parotidectomy is an efficient surgical treatment modality for pleomorphic adenoma of the parotid gland, although some morbidity may occur. In this study, the median time interval between primary surgery and the presentation of the recurrent tumor was observed to be 14.4 years.

OBJECTIVE

Analysis of the long-term results of patients undergoing lateral or total parotidectomy as first-line treatment of parotid pleomorphic adenoma at our institution between the years 1979 and 1996.

METHODS

The individual patient charts of 230 patients were feasible for retrospective analysis in 2007.

RESULTS

In all, 42 patients had dysfunction of the facial nerve after the primary surgery, but only 14 of them had permanent dysfunction. A recurrent tumor occurred in nine cases (3.9%). The time interval between primary surgery and the first recurrence ranged from 7.1 to 24.5 years. Recurrent tumors were treated with surgery, two patients received additional radiotherapy.

Survey of opinions on the management of pleomorphic adenoma among United Kingdom oral and maxillofacial surgeons

OBJECTIVES

This study aims to highlight the current points of view regarding the management of pleomorphic adenomas among oral and maxillofacial surgeons in the United Kingdom.

PATIENTS AND METHODS

A questionnaire was drafted and sent to all the consultant members of the British Society of Oral Maxillofacial Surgery (n=263). The survey evaluated the surgical experience of the surgeon, the preferred surgical treatment of a newly diagnosed 3 cm diameter pleomorphic adenoma in the superficial lobe of the parotid gland in an adult and a child, and the treatment options of pleomorphic salivary adenoma (PSA) with the four following scenarios: (i) PSA with complete excision or incomplete excision; (ii) PSA with carcinoma in situ (atypical pleomorphic adenoma) with complete excision or incomplete excision; (iii) PSA with non-invasive malignant transformation with complete or incomplete excision; and (iv) carcinoma in PSA with complete or incomplete excision. The initial response was low so two reminders were sent to increase the rate of response.

RESULTS

The final response rate was 67%. The results showed that there was no significant difference in the opinions of the respondents regarding treatment of pleomorphic adenoma in both adults and children. Seventy-five (56.4%) of 133 surgeons were treated the multinodular recurrence in older patients with surgery combined with radiotherapy. One-hundred and five (78.9%) surgeons were treated older patients with solitary recurrence with surgery alone. There was a consensus on complete excision for the treatment of carcinoma in situ (atypical pleomorphic adenoma) or PSA with non-invasive malignant transformation.

CONCLUSION

This survey shows that superficial parotidectomy is the standard treatment method for primary pleomorphic adenoma in children and adults. Surgery combined with radiotherapy is the preferred option in the case of multinodular recurrence, and surgery alone is recommended in the case of a solitary recurrence.

Pleomorphic adenoma of the submandibular gland: an evolving change in practice following review of a personal case series

We reviewed patients with submandibular gland pleomorphic adenoma treated at a tertiary referral centre in the United Kingdom (1988-2004). Thirty-seven patients were identified, 32 newly diagnosed cases and 5 cases of recurrent disease previously treated elsewhere. The exact pre-operative diagnosis was "unknown" in 76% of the new cases. All cases were surgically excised (41% with extracapsular gland excision and 59% by selective level Ib, IIa and III neck dissection). Temporary marginal mandibular nerve neuropraxia was documented in 25% of cases. All 32 new cases remain clinically tumour free at the time of writing. In patients with recurrent disease, complete microscopic tumour clearance was achieved in three of the five cases, however all remain clinically tumour free. Pleomorphic adenomas of the submandibular gland are uncommon, with good prognosis following complete tumour excision. Recurrent tumours, however, are frequently multi-focal and difficult to excise completely. The adequacy of primary surgery is crucial and supports an approach for a more radical excision primarily by a selective level lb, IIa and III neck dissection; ensuring complete disease clearance for pleomorphic adenoma, avoiding the risks of tumour spillage associated with a limited excision and tumour handling; and removing the primary echelon of lymph nodes at risk of metastasis if the pathology turns out to be malignant.

Case-report: metastasizing pleomorphic adenoma of the parotid gland

CASE-REPORT

Metastasizing pleomorphic adenoma of the parotid gland. We present a case of metastasizing pleomorphic adenoma (MPA). The patient died in 2002 at the age of 64 years, following on an initial diagnosis of a pleomorphic adenoma of the right parotid gland at the age of nineteen, multiple local recurrences and finally rib metastases. Histological examination of the excised tissue from the parotid gland and the metastases showed it to be a pleomorphic adenoma without any signs of malignancy, although the metastatic deposits consisted mostly of a myoepithelial component. Both in our case as in most of the literature, MPA follows a probable incomplete removal of the first tumour. We conclude that the first operation is of great importance for the prevention of late recurrences and metastatic spread.

Mucoepidermoid carcinoma arising from pleomorphic adenoma of the soft palate

Carcinoma arising in pleomorphic adenoma is a rare entity. A case of mucoepidermoid carcinoma in pleomorphic adenoma occurring in the soft palate of a 40-year-old woman is reported. An intraoral excision of the tumor was performed. Histopathological examination revealed high-grade mucoepidermoid carcinoma proliferated in pleomorphic adenoma with free surgical margin. The patient received adjuvant neck radiotherapy. She remains free of disease 16 months post-treatment.

The role of postoperative radiation therapy in carcinoma ex pleomorphic adenoma of the parotid gland

PURPOSE

To evaluate the impact of postoperative radiation therapy on the clinical course of patients with carcinoma ex pleomorphic adenoma of the parotid gland.

METHODS AND MATERIALS

Between 1960 and 2004, 63 patients were treated with definitive surgery for carcinoma ex pleomorphic adenoma of the parotid gland. Forty patients (63%) received postoperative radiation therapy to a median dose of 60 Gy (range, 45-71 Gy). Adenocarcinoma (29 patients), salivary duct carcinoma (16 patients), and adenoid cystic carcinoma (9 patients) were the most common malignant subtypes. Pathologic T -stage was: 16% T1, 33% T2, 32% T3, and 19% T4. Twenty-one patients (33%) had microscopically positive margins and 39 (62%) had perineural invasion. Median follow-up was 50 months (range, 2-96 months).

RESULTS

The use of postoperative therapy significantly improved 5-year local control from 49% to 75% (p = 0.005) and was associated with an improvement in survival among patients without evidence of cervical lymph node metastasis (p = 0.01). A Cox proportional hazard model identified pathologic involvement of cervical lymph nodes as an independent predictor of overall survival. Overall survival was 16% for patients with pathologic N-positive disease compared with 67% for those whose lymph node status was negative or unknown (p = 0.001).

CONCLUSION

Surgery followed by postoperative radiation should be considered the standard of care for patients with carcinoma ex pleomorphic adenoma.

Epithelial lacrimal gland tumors: a clinicopathological study of 18 cases

OBJECTIVE

The aim of this study was to report the clinicopathological features of 18 epithelial tumors of the lacrimal gland treated in a single institution.

STUDY DESIGN AND SETTING

Clinical data and treatment were recorded and histological features reviewed.

RESULTS

Twelve tumors (66.7%) were adenoid cystic carcinoma (ACC), 5 (27.8%) pleomorphic adenoma (PA), and 1 (5.5%) carcinoma ex pleomorphic adenoma. All patients with ACC presented with advanced clinical stage, and most were treated by wide surgical resection followed by adjuvant radiotherapy. No recurrence was observed in 4 cases of ACC; however, 7 patients died from persistence of disease or by local and/or distant recurrence. All PA patients were successfully treated by surgical resection.

CONCLUSIONS

Epithelial lacrimal gland tumors are mainly PA and ACC, and malignancies are more common than benign tumors. Although ACC presented typically with advanced clinical stage, 33% of the patients survived without tumor recurrence or metastasis.

Recurrent pleomorphic adenoma of epipharynx following irradiation therapy

We present a case of a 67-year-old female patient having a pleomorphic adenoma of epipharynx with intact fibrous capsula, which despite its benignity recurred and, moreover, responded quite well to irradiation therapy. The patient, at first, refused any therapy. Three years later, when the CT showed tumor enlargement she accepted only irradiation therapy, resulting in significant reduction of tumor size. Five years later the tumor recurred but without malignant transformation. She still refused surgery, but accepted re-irradiation therapy. After a three-year follow-up the patient has no symptoms of the tumor enlargement. This case shows that the irradiation therapy might be quite effective in the treatment of pleomorphic adenoma of epipharynx, but it is clear that much better results could be accomplished in combination with the surgery. In cases when the surgery is rejected or not possible because of the vicinity of the vital structures, we recommend the irradiation therapy as a therapy of the choice.

Increased carotid wall thickening after radiotherapy on the neck

Patients treated for head and neck tumours with local radiotherapy (RT) on the neck harbour an increased risk of stroke. This may be due to accelerated atherosclerotic changes within the RT-field; however, the real impact of local RT on the carotid artery remains debatable. The aim of the present study was to assess the difference in carotid wall thickness (intima-media thickness) in 42 unilaterally irradiated parotid tumour patients by performing B-mode ultrasonography. A mean difference in intima-media thickness (IMT) of the irradiated compared with the non-irradiated carotid artery of 0.30 mm (P=0.031) was found. A significant correlation was established with a longer post-RT interval (P=0.008). RT on the neck is associated with increased thickening of carotid IMT. Screening and treatment of additional cerebrovascular risk factors which contribute to further IMT thickening and stroke development is recommended, especially in radiotherapy patients with a favourable prognosis.

Role of Radiotherapy for Pleomorphic Adenoma

The purpose of this article was to evaluate the role of radiotherapy (RT) in the treatment of pleomorphic adenoma. This is a retrospective analysis of 17 patients treated with RT alone (2 patients) or combined with surgery (15 patients). Follow up ranged from 1.8 to 27.1 years (median, 9.6 years). Local control was obtained in 8 of 10 patients (80%) with subclinical disease and 3 of 7 patients (43%) with gross disease. Overall local control was obtained in 11 of 17 patients (65%). The 5- and 10-year overall local control rates were 69% and 61%, respectively. One patient died secondary to tumor extension into the central nervous system, 1 patient had recurrence of carcinoma ex-pleomorphic adenoma and died of cancer at the primary site, 5 patients died free of disease, and 10 patients were alive at last follow up. RT is relatively effective at controlling subclinical disease in patients at high risk for developing recurrence after surgery for pleomorphic adenoma. Limited data suggest that RT may also occasionally control gross disease.

Neck masses secondary to heterotopic salivary gland tissue: a 25-year experience

OBJECTIVES

The aim of this study is to review salivary tumors arising from heterotopic salivary inclusions in the periparotid and cervical lymph nodal tissues over a 25-year span.

METHODS

A retrospective chart review revealed 24 patients with asymptomatic neck masses treated between 1976 and 2001, whose pathology demonstrated heterotopic salivary tissue or neoplasms arising from heterotopic salivary tissue.

RESULTS

Nine cases were benign periparotid lymph nodes with heterotopic salivary inclusions, 3 of which had multimodal involvement. Fifteen cases of heterotopic salivary tumors were identified. The benign tumors were predominantly Warthin's tumor (8) with 1 pleomorphic adenoma. Malignant tumors included mucoepidermoid (3), acinic cell (2), and adenocarcinoma (1). Patients were treated by a superficial parotidectomy, neck dissection, or simple excision depending on site and preoperative workup. Adjuvant radiation therapy was included for high-grade malignancies. Among the 15 tumor patients, follow-up ranged from 1 month to 17 years. Nine patients are alive and disease-free, 5 are deceased, and 1 was lost to follow-up.

CONCLUSIONS

Heterotopic salivary tissue in periparotid and upper cervical nodes is a more common occurrence than historically recognized. Tumorigenic changes arise from heterotopic nodal inclusions, and although infrequent, should be considered in the differential diagnosis for isolated neck/periparotid masses and parotid Warthin's tumor. Suggested management, after a thorough clinical exam/needle aspiration biopsy, includes an imaging survey of the parotid gland and neck lymphatics with an appropriate resection to include a simple excision, parotidectomy, neck dissection, and/or irradiation as indicated. Isolated low-grade malignant lesions/benign lesions are adequately managed by excision or parotidectomy alone. High-grade malignant lesions require more extended surgery with possible irradiation.

Adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct: a case report

OBJECTIVES

To present the clinical presentation, workup, surgical approach, and pathological findings of the first case report of a patient with adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct.

STUDY DESIGN

Retrospective review of the records of a case of adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct.

METHODS

The clinical presentation, workup, surgical approach, and pathological findings were reviewed.

RESULTS

A 51-year-old man presented with a 10-year history of recurrent epiphora of the right eye. At dacryocystorhinostomy a small lesion was visualized within the lumen of the lacrimal sac. A biopsy specimen was consistent with adenocarcinoma. En bloc resection was accomplished using a lateral rhinotomy and medial maxillectomy. The final specimen showed adenocarcinoma ex-pleomorphic adenoma. The patient was given postoperative radiation therapy. He was free of disease 16 months after treatment.

CONCLUSIONS

Lacrimal sac tumors should be considered in the differential diagnosis of chronic epiphora. Management of nasolacrimal adenocarcinoma requires complete surgical resection. Radiation treatment in and of itself is not curative but may be useful as adjuvant therapy. Carcinoma ex-pleomorphic adenoma can develop in the lacrimal sac and nasolacrimal duct.

Expression of PLAG1 and HMGIC proteins and fusion transcripts in radiation-associated pleomorphic adenomas

Extensive cytogenetic investigations of pleomorphic adenomas of the salivary glands have unequivocally demonstrated that they are cytogenetically monoclonal and are characterized by a high frequency of tumor specific chromosome abnormalities involving in particular chromosome bands 3p21, 8q12 and 12q14-15. Here we show that two radiation-associated and cytogenetically polyclonal adenomas without gross rearrangements of these breakpoints show simultaneous overexpression of the PLAG1 and HMGIC genes, i.e. the target genes of the 8q12 and 12q14-15 rearrangements in sporadic adenomas. In addition, one of the tumors expressed a cryptic CTNNB1-PLAG1 fusion transcript. Our findings strongly suggest that identical or very similar molecular mechanisms are operating during adenoma tumorigenesis irrespective of whether the tumors are cytogenetically polyclonal or whether they have non-random, tumor specific abnormalities. Cytogenetically polyclonal adenomas are thus most likely also of monoclonal origin.

Neutron radiotherapy for recurrent pleomorphic adenomas of major salivary glands

INTRODUCTION

Pleomorphic adenoma is the most common neoplasm arising in the salivary glands. Surgical management is the primary therapeutic modality. With the use of modern surgical techniques, recurrence is infrequent, and facial nerve sparing is the norm. However, for patients with recurrent disease, the risk of further relapses is increased with surgical resection alone, particularly for those patients in whom multiple recurrences have already occurred. The role of adjuvant radiotherapy in this setting remains uncertain. Although neutron radiotherapy is superior to conventional radiotherapy for malignant salivary gland tumors, its role in the treatment of pleomorphic adenomas is less well defined. We report our experience using this modality for high-risk, recurrent pleomorphic adenomas.

METHODS

Sixteen patients were treated with neutron radiotherapy for recurrent pleomorphic adenomas of major salivary glands from 1986 through 1993. The median age at diagnosis was 33 years (range, 11-77 years); median age at the time of neutron radiotherapy was 52 years (range, 22-77 years); median number of prior surgical procedures was 3 (range, 1-6); median duration from initial diagnosis to radiotherapy was 14.5 years (range, 3 months-30 years); median follow-up was 83 months (range, 9-144 months). The median period at risk for survivors was 96 months (defined as the interval from completion of neutron radiotherapy to last follow-up). Ten patients had evidence of gross residual disease at the time of treatment as determined by imaging studies, with nine patients having multinodular disease.

RESULTS

The 10-year actuarial survival was 79%. One patient died from lung metastases 9 months after treatment; one patient died from a liver tumor of uncertain origin, but the histology could not rule out a metastasis from the previous pleomorphic adenoma; and one patient died from recurrent disease at the base of skull. The 15-year actuarial locoregional control rate was 85%. One of the two patients with locoregional recurrence had a malignant transformation into an adenocarcinoma. No statistical difference in 15-year actuarial survival (75% vs 83%, p =.82) was found comparing patients with gross residual disease vs microscopic residual disease. The actuarial 15-year locoregional control was 76% for patients with gross residual disease vs 100% for those with microscopic disease. The 15-year actuarial risk of RTOG/ESTRO nonaudiologic grade III/IV complications was 21%. No facial nerve injuries were observed as a direct consequence of neutron radiotherapy.

CONCLUSIONS

Neutron radiotherapy offers both excellent local control rates and survival rates in patients with multiply recurrent pleomorphic adenomas that are not candidates for surgical resection, even in the presence of gross residual disease. The treatment-related morbidity is acceptable. Malignant transformations and metastases, although uncommon, may be observed in this tumor.

High-dose-rate endobronchial brachytherapy in endobronchial metastatic malignant chondroid syringoma

A 65-year-old man with malignant chondroid syringoma (MCS) was found to have pulmonary metastases in the form of multiple pulmonary nodules 4 years after wide excision and adjuvant radiotherapy of a primary abdominal wall tumor. Atelectasis of the lingula due to obstructive endobronchial metastasis, resistant to combination chemotherapy, led us to perform high-dose rate (HDR) endobronchial brachytherapy for the first time in this rare tumor with a favorable response. This case emphasizes the role of HDR brachytherapy as a palliative procedure in endobronchial tumors not responding to other treatment modalities, even those considered to be radioresistant.

Carcinoma ex pleomorphic adenoma: a clinicopathologic review

BACKGROUND

Carcinoma ex pleomorphic adenoma (CXPA) is an aggressive, poorly understood salivary gland malignancy. Misdiagnosis is common, because the residual mixed tumor component may be small, and various carcinoma subtypes are possible.

METHODS

We retrospectively reviewed the medical records of 73 patients with major salivary gland CXPA treated at our institution from 1960 to 1994. Of the 73 patients, 66 had primary tumors and 7 had recurrent tumors; 47 were men, and 26 were women; the mean age was 61 years.

RESULTS

Adenocarcinoma (31 cases) and salivary duct carcinoma (24 cases) were the most common malignant subtypes. All patients were treated surgically, and 32 also had radiation therapy. Of 66 patients with primary tumors, 23% had local recurrence. Metastasis (either initial or delayed) occurred regionally in 56% and distantly in 44%. Thirty-six patients (55%) died of the disease. At 3 years, overall survival was 39% and at 5 years, 30%.

CONCLUSIONS

Important prognostic factors include tumor size, grade, and clinical and pathologic stage. Patients with minimally invasive tumors (<5 mm) should do well with appropriate surgical treatment.

Recurrent malignant chondroid syringoma of the foot: a case report and review of the literature

Malignant chondroid syringoma, or mixed tumor of the skin, salivary gland type, is an uncommon neoplasm believed to originate in sweat glands. This neoplasm occurs mostly in women and is typically seen in the extremities and torso. A case of recurrent malignant chondroid syringoma of the right foot in a man aged 34 years is described with a review of pertinent literature. The surgically excised neoplasm was evaluated by routine histology, immunohistochemistry, and transmission electron microscopy. The malignant chondroid syringoma showed microscopic dermal satellite tumor nodules. Immunohistochemical staining was positive for keratin and S100 and negative for actin and p53. Ki-67 showed <10% positive staining. Ultrastructurally, the neoplasm was composed of epithelial cells with tonofilaments, cell junctions, and electron-dense amorphous keratin-like substance in the intercellular spaces. No evidence of myoepithelial differentiation was noted. Given the tumoral size, acral location, and histologic findings, the neoplasm was classified as a malignant chondroid syringoma. After reviewing the literature, it became apparent that wide surgical excision, adjuvant radiation therapy as well as patient education are critical in facilitating long-term survival.

Treatment of recurrent pleomorphic adenomas of the parotid gland

Recurrent pleomorphic adenomas (RPAs) of the parotid gland are an uncommon but challenging problem. The records of 31 patients with RPAs were reviewed to assess the clinical presentation and treatment results. More than half of these patients underwent total parotidectomy. Local control was achieved in 94% of patients at 7 years (median follow-up 7.3 years). Patients who had surgery for recurrence after a formal parotidectomy were more likely to have another recurrence (63% local control at 7 years) than patients whose initial procedure was a limited excision (100% local control at 7 years; P < 0.01). Better local control was seen in 11 patients who received postoperative irradiation (100% at 10 years) than in 20 patients who did not (71% at 10 years; P < 0.28). Adequate surgical resection yields an acceptable local control rate in patients with RPAs. Postoperative radiation therapy may improve control in patients at high risk for another recurrence.

Cerebral radionecrosis following the treatment of parotid tumours: a case report and review of the literature

Radiotherapy is an accepted part of the treatment of malignant tumours of the parotid gland. The use of radiotherapy in benign parotid tumours, where spillage of tumour cells has occurred at operation, is more controversial. Radiotherapy to the parotid bed is not without morbidity. Complications may arise as a result of radiation damage to neighbouring structures and there is also potential to induce malignant disease. A patient, whose postoperative radiotherapy following resection of a pleomorphic salivary gland adenoma was complicated by cerebral necrosis, is discussed. The literature pertaining to morbidity of radiotherapy for parotid tumours is reviewed.

Atypical acute reaction associated with radiotherapy: a case report

Radiation therapy may cause acute and/or chronic skin reactions. In this paper a patient with contact urticaria associated with irradiation is described. We could not determine the agent behind the contact urticaria in our patient in light of the current literature. We are reporting this case because the literature neither mentioned radiotherapy as being among the agents that lead to contact urticaria nor reported contact urticaria as being among the acute reactions to radiotherapy.

Treating recurrence of parotid benign pleomorphic adenomas

Treatment for recurrence after surgical removal of parotid benign pleomorphic adenoma (PBPA) has not been well defined and is often followed by further recurrence. Surgery is overwhelmingly the most common approach. The risk of facial nerve injury is greater at reoperation since the nerve is less well defined. The value of radiation therapy (RT) has not been determined and incurs with it the risk of possible late occurrence of malignancy or nerve damage. The charts of patients with recurrent PBPA treated consecutively by a single surgeon from 1965 to 1993 were reviewed. All patients had a histopathologically verified diagnosis of PBPA both at the time of primary and subsequent surgeries. Follow-up was obtained from clinical charts and correspondence communication. Recurrence curves were generated using the Kaplan-Meier method. Thirty-nine patients with recurrent PBPA (36 referred and 3 treated primarily at Mayo) were evaluated. The patients were classified according to the type of surgery: 14 patients had previously undergone some form of parotidectomy or had only resection of the tumor for recurrence, and 25 patients underwent parotidectomy since this had not been performed primarily. The mean age in the two groups was 49 and 50 years respectively. The mean follow-up was 10 years after the recurrence treatment. The mean time between initial resection and recurrence in the two groups was 14 and 15 years. The mean time between the recurrence treatment and a second recurrence was 7.5 years. Nine patients had RT in addition to the local resection. Of this group 3 patients (33%) developed another recurrence. Five patients had local resection only, and of this group 1 patient (20%) developed another recurrence. Of the group that had superficial parotidectomy, 3 patients had additional RT and one of these patients (33%) developed another recurrence. Twenty-two patients had superficial parotidectomy only, and of this group 3 patients (14%) developed another recurrence. Only 2 of the 39 patients had complications. One patient developed Frey's syndrome after superficial parotidectomy and 1 patient developed facial paralysis after RT. As in other series, the number of patients is inadequate to allow for firm conclusions. However, it appears that when previous parotidectomy has been performed, simple excision with a margin of surrounding tissue would seem appropriate. Parotidectomy should be carried out if not performed previously. In simple excision after previous parotidectomy, there is a greater risk to the facial nerve because of difficulty in distinguishing the facial nerve from surrounding scar tissue. Our preference is to use general anesthesia so that branches of the nerve are not paralyzed and stimulation of the nerve aids in safe dissection. The value of RT is still indeterminate.

Clinically aggressive metastasizing pleomorphic adenoma: report of two cases

BACKGROUND

It has been suggested that metastasizing pleomorphic adenomas may represent unrecognized malignancy.

METHODS

The cytologic and clinical characteristics of two metastasizing pleomorphic adenomas diagnosed by fine-needle sampling are reported.

RESULTS

Both showed malignant evolution: the primary tumors arose from the palate and the parotid salivary glands, respectively. Metastases occurred simultaneously with local recurrence in the first patient and after a second local recurrence in the second patient. Both patients were treated by surgery and radiotherapy but died of disseminated disease 8 and 4 years after initial diagnosis. No histologic evidence of malignancy was observed on cytology smears or histology sections in either case.

CONCLUSION

Clinically, our cases support the hypothesis that metastasizing pleomorphic adenomas represent unrecognized malignancy, because the biologic course of two tumors led to unequivocally lethal outcome.

The surgical management of recurrent or residual pleomorphic adenomas of the parotid gland. Analysis and results in 40 patients

From 1974 to 1995, 40 patients were treated surgically at the University Hospital Vrije, Universiteit Amsterdam for recurrent or residual pleomorphic adenomas of the parotid gland after previous surgery. The median interval between the initial procedure and surgery for the recurrence was 122 months. Eleven patients had one or more attempts to resect tumor recurrences prior to referral. During reoperation at this institution it was decided to refrain from tumor resection in three patients. Tumor control in two of these patients was achieved using radiotherapy. In the third patient a "wait-and-see" policy was adopted. The other 37 patients underwent en bloc surgical excisions of their tumor and/or previously incised tissues. Among the 36 patients operated for histopathologically benign disease, 16 received postoperative radiotherapy (to 6500 cGy). None developed a further recurrence, the median follow-up being 106 months. Only one of these patients experienced permanent segmental facial nerve paralysis. Malignant transformation of tumor occurred in two patients. One of these patients died of locoregional disease after surgery and radiotherapy. Radical tumor resection was deferred in the other patient, with tumor control achieved using radiotherapy (7000 cGy). However, since recurrent disease tends to be multifocal in origin, prolonged routine follow-up is required.

Surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland

BACKGROUND

Recent modifications of surgical technique may have influenced outcome following parotidectomy. This retrospective study compares the results of the different surgical methods with regard to recurrence rate and the effects on morbidity between 1974 and 1994.

METHODS

A total of 246 primary surgical parotid procedures were performed on 245 patients for pleomorphic adenoma. These included 131 'partial' superficial parotidectomies, 61 'total' superficial parotidectomies, 30 partial superficial/deep lobe parotidectomies, eight total parotidectomies, and 16 'selective' deep lobe parotidectomies. In the recent past, the posterior branch of the greater auricular nerve was preserved in the majority of patients. Eleven patients received postoperative radiotherapy. Median follow-up was 95 months. Fourteen patients died without recurrent tumour.

RESULTS

Two patients (0.8 per cent) developed local recurrence, both after total parotidectomy for a deep lobe tumour. No patient experienced permanent facial nerve palsy. The incidence of gustatory sweating for partial superficial parotidectomy was 6.9 per cent (nine of 131) compared with 13.1 per cent (eight of 61) for total superficial parotidectomy.

CONCLUSION

Partial parotidectomy is an effective treatment for the majority of pleomorphic adenomas; local recurrence is rare and morbidity is low. Prolonged follow-up is unnecessary.

Long-term follow-up of over 1000 patients with salivary gland tumours treated in a single centre

Between 1947 and 1992, 1403 patients with 1432 salivary gland tumours were treated at the Christie Hospital, Manchester. There were 1194 epithelial neoplasms: parotid, 1082 (91 per cent); submandibular, 47 (4 per cent); minor glands, 65 (5 per cent). The commonest histological diagnoses were pleomorphic adenoma (n = 776) and adenolymphoma (n = 159). A total of 244 carcinomas were seen (adenoid cystic carcinoma, n = 75). Treatment was primarily surgical, conservative where possible, and determined by tumour extent and not histology. Adjuvant radiation therapy was used in over half the definitively treated malignancies. The recurrence rate following the treatment of 551 new parotid pleomorphic adenomas was 1.6 per cent at median follow-up 12.5 (range 1-34) years, increasing to 15 per cent in the secondarily referred group (n = 170). For patients with definitively treated primary salivary carcinomas (n = 148), the disease-free survival rate at 5, 10 and 15 years was 58, 47 and 45 per cent respectively. Using multivariate analysis, clinical stage was the most important predictor of survival; the 10-year survival rate for stages I-IV was 96, 70, 47 and 19 per cent respectively.

An analysis of the treatment of 114 patients with recurrent pleomorphic adenomas of the parotid gland

BACKGROUND

Nerve preserving surgery is widely recommended for recurrent parotid pleomorphic adenomas though the risk of further relapse may be high. Adjuvant radiotherapy may improve control but its exact role requires clarification.

METHODS

A series of 114 patients with first recurrences treated between 1952 and 1992 is reviewed. Treatment modality was either surgery alone (SG; n = 63) or surgery with radiotherapy (SG + RT; n = 51). Results were determined with respect to long-term tumor control (K-M life-tables) and facial nerve function.

RESULTS

The rate to second recurrence was 15% (17/114), median follow-up 14 years. There were no cases of malignant degeneration. Multinodular recurrences treated by SG were at particular high risk of relapse, but control was significantly improved with adjuvant radiotherapy (SG versus SG = RT; 43% versus 4% at 15 years, P = 0.008). In contrast, no difference was demonstrated in the uninodular tumor group (SG versus SG = RT; 15% versus 13% at 15 years, P = 0.9). The incidence of permanent facial nerve injury was 15%.

CONCLUSIONS

This study emphasizes the distinction between multinodular and uninodular recurrences; the former is at high risk of relapse and benefits from adjuvant radiotherapy whereas solitary tumors may be adequately treated by surgery alone.

Role of radiation therapy in the management of malignant chondroid syringoma

BACKGROUND

Malignant sweat gland neoplasms are exceedingly rare tumors. Malignant chondroid syringoma (MCS) is one of the rarest subtypes, and as such, still poorly understood. It lacks distinctive clinical features, often delaying initial diagnosis and therapeutic management.

OBJECTIVE

A current case and the available literature are reviewed to determine the overall clinical course of the MCS and the potential role of adjuvant therapy.

METHODS

A case of MCS was studied by light microscope, immunohistochemistry, and electron microscopy. The clinical data of this case and of other reported cases are summarized and compared.

RESULTS

This tumor recurred locally after initial local excision. Subsequent re-excision and radiation therapy rendered the patient without evidence of disease. This case study and the literature review of the 20 reported cases indicate that MCS is highly recurrent with tendency toward metastasis.

CONCLUSION

MCS appears to behave in an aggressive manner. An initial treatment modality is aggressive surgery. Adjuvant radiation therapy with or without chemotherapy should be tried in future cases.

Pleomorphic adenoma: effect of tumor spill and inadequate resection on tumor recurrence

Intraoperative tumor spill or inadequate resection may be associated with an increase in the recurrence rate of pleomorphic adenoma. An attempt was made to determine the recurrence rate when such factors were identified at the time of operation. From 1970 through 1989, 17 cases were identified in which there was a question of intraoperative tumor spill or inadequate resection of a salivary gland pleomorphic adenoma. Patients were either observed or given postoperative irradiation with a mean follow-up of 7.4 years. The overall initial local recurrence rate was 24%, and all recurrences were successfully salvaged. Inadequate resection, particularly enucleation, was predictive of local recurrence, but tumor spill was not. Postoperative irradiation after inadequate resection appeared to decrease the probability of recurrence. We conclude that recurrence of pleomorphic adenoma is not increased by tumor spill as compared with inadequate resection.

Post-irradiation carcinosarcoma of the parotid gland

Carcinosarcoma of the salivary glands are rare tumours, often associated with a history of pleomorphic adenoma. A case of carcinosarcoma of the parotid arising following irradiation to the resection site of a pleomorphic adenoma is presented. The clinical and histological features are discussed and the literature reviewed.

Carotid artery stenosis following adjuvant radiotherapy for a parotid pleomorphic adenoma

Carotid artery stenosis following radiotherapy for head and neck cancer is probably underdiagnosed. We report a symptomatic case and suggest that greater awareness of the condition should result in suitable investigation and appropriate medical or surgical treatment.

Fast neutron radiation for recurrent pleomorphic adenomas of the parotid gland

Between 1984 and 1989, six patients with recurrent pleomorphic adenomas of the parotid gland were treated with fast neutron radiotherapy. All of the patients in this series had one or more unfavorable prognostic features, which would predict suboptimal local tumor control rates with the utilization of standard surgical and adjuvant photon/electron radiation therapies. These prognostic features included multiply recurrent disease in three patients, known gross postoperative residual disease in one patient, extensive unresectable disease in one patient, and multiply recurrent disease plus gross postoperative residual disease in one patient. Patients had an average of three surgeries for recurrent adenomas before their neutron irradiation. The median period from the original diagnosis to the time of neutron treatment was 11 years, with a range of 1.3-32 years. With a median follow-up of 52 months, an overall local control rate of 100% was achieved. Only one grade III (European Organization for Research and Treatment of Cancer-Radiation Therapy Oncology Group scale) late complication occurred secondary to the neutron irradiation. Similar to their malignant counterparts, benign salivary gland neoplasms appear to display excellent response and control rates to treatment with fast neutron irradiation. Neutron irradiation of pleomorphic adenomas should be considered an appropriate therapeutic approach in situations, such as recurrent disease and postoperative gross residual disease, where one may be concerned about potential local failures with the use of standard surgical and radiotherapeutic modalities. Neutron radiation also carries a low risk of facial nerve damage, a consideration that may argue for limiting the extent of surgical resection of recurrent disease.

[Results of photon therapy of malignant tumors of the parotid gland]

Between 1971 and 1982 86 patients have been treated because of a malignant tumor of the parotid gland. 64 patients have been irradiated after complete (n = 49) or incomplete (n = 15) first resection. 12/64 (19%) relapsed locally. The loco-regional tumor control rate five and ten years after postoperative radiotherapy is 72%, 85% after complete resection, and 22% after incomplete resection (p less than 0.01). Tumor size and nodal disease are of prognostic value. Disease-free survival in patients without lymph nodes is 53%, with lymph node metastases 31% after five years (p less than 0.05). Small tumors (T1, 2) have a better local control rate compared to locally advanced tumors (five years: 83% vs. 53%, p less than 0.05). No difference was found neither for the total dose nor the histology of the tumor. Distant metastases became apparent after median eleven months.

Radiotherapy for pleomorphic adenoma of the parotid gland

A study was made of 187 patients with parotid pleomorphic adenoma treated by radiotherapy. This followed surgery but with incomplete removal or tumor spillage. In the early years of the study radiotherapy was given by radium needle implant done usually at the time of surgery, but from the late 1960s beam-directed external radiotherapy with a head shell was used most commonly. A 3-field technique or wedge pair was the standard technique. The median age was 46 with nearly half the patients (87/187) aged between 40 and 60, and the ratio of women to men was 1.4:1 (110:77). Median follow-up for all patients was 14 years. One hundred fifteen patients had radiotherapy immediately after their first operation with a recurrence rate of 0.9% (1/115). Of the 115 there were 2 cases of radionecrosis (1 major, 1 minor), 1 case of permanent facial nerve palsy, 1 Frey Syndrome (post-gustatory sweating), and 1 salivary fistula. Seventy-two patients had radiotherapy delayed until one or more recurrences had been surgically treated. Nine (12.5%) of these developed yet further recurrence after radiotherapy. There were 2 cases of radionecrosis (1 major), 4 cases of facial nerve palsy (3 of which were complete), 16 cases (22.2%) of Frey Syndrome, and 1 case of malignant change in a parotid tumor. In addition one squamous cell carcinoma developed at the site of a needle implant 25 years later. Recurrences after radiotherapy continued beyond 20 years of follow-up. Patients having unsatisfactory surgery due to spill at operation or residual tumor left behind should have radiotherapy immediately and not delayed until local recurrence occurs because of the increased morbidity and the higher incidence of yet further recurrence.

Preservation of the facial nerve in the management of recurrent pleomorphic adenoma

Whether to preserve or sacrifice a facial nerve involved with benign neoplasm is one of the most difficult intraoperative decisions confronting the head and neck surgeon. We reviewed 21 cases of recurrent pleomorphic adenoma treated with subtotal excision and facial nerve preservation, followed by postoperative radiation therapy. Of the 17 patients with microscopic residual tumor at completion of surgery, 16 (94%) remain free of recurrence with an average follow-up of 5.9 years. Only one of four patients (25%) with a large postoperative tumor load remains free of disease. Facial nerve function is normal in 20 of 21 patients. Preservation of the facial nerve with postoperative irradiation should be considered as an alternative to nerve sacrifice in selected cases of recurrent pleomorphic adenoma.

Photon irradiation of unresectable carcinomas of salivary glands

This paper presents our experience and the local control rates of a group of patients with inoperable and unresectable lesions treated by photon irradiation from 1980 through 1989. The patient material consists of a total of 24 patients, 9 with carcinoma arising from the parotid gland and 15 with lesions in the minor salivary glands, mainly the oral cavity and oropharynx. The pathologic slides were reviewed and malignancy of various cell types confirmed. The 5-year actuarial local control of parotid gland lesions after photon irradiation was 100% and the survival rate was 65%. For the minor salivary gland lesions, the 5-year actuarial local control was 78% and the survival rate with or without disease was 93%. All lesions were irradiated by accelerated hyperfractionated photons (bid) with 1.6 Gy per fraction, intermixed with various boost techniques including electron beam, intraoral cone, interstitial implant, and/or submental photons for a total of 65-70 Gy. Most treatment failures of parotid cancer were due to distant metastases. The present series showed excellent local control and satisfactory survival of inoperable and unresectable salivary gland carcinomas after state-of-the-art photon irradiation, comparable to that achieved by neutron irradiation. The late complications were minimal. A controlled randomized trial may be indicated.

Late audiovestibular consequences of radical radiotherapy to the parotid

It has been claimed that the inner ear is generally resistant to the effects of radiotherapy schedules commonly used for treating head and neck cancer. A study was made of 28 patients previously irradiated for parotid pleomorphic adenoma to assess the effect on the audiovestibular apparatus. The dose most commonly used was 50 Gy in 15 daily fractions over 20 days and the median interval between radiotherapy and assessment was 14 years. Of 28 patients 15 had significant hearing deficit on the irradiated side on audiometry and this was predominantly sensorineural in type. In addition seven of these 15 patients had semicircular canal paresis. The reason for this morbidity may be arithmetic (total biological dose; dose per fraction) or geometric (upper extent; depth of target volume). Patients are now routinely warned of the possibility of late audiovestibular effects following radical radiotherapy to the parotid.

Management of the parotid pleomorphic adenoma, the problem of exposing tumour tissue at operation. The logical pursuit of treatment policies

The objective of treatment of a parotid pleomorphic adenoma is to remove all tumour cells with minimal short- and long-term morbidity and minimal recurrence rates. If an enucleation is carried out, the facial nerve may be put at risk and tumour fragments will inevitably be left in the wound. Most surgeons suggest that after enucleation, radiotherapy must be given to reduce the recurrence rate to an acceptable level. If during a formal superficial parotidectomy the tumour capsule is visualised, the objective of removing the tumour with an intact cuff of normal tissue has failed and the operation has in effect become an enucleation. This paper defines the problem and discusses its management.

Radiotherapy in epithelial tumors of the parotid gland: case presentation and literature review

A group of 113 patients irradiated for parotid tumor was studied retrospectively. Sixty-two patients were irradiated after superficial parotidectomy or enucleation of a pleomorphic adenoma. None of them had a recurrence after 5-15 years. Sixteen patients were irradiated postoperatively after surgery for a recurrence of pleomorphic adenoma. Only one of them had developed a recurrent tumor. Thirty-five patients with a malignant parotid tumor were treated by irradiation, 22 after surgery and 13 after biopsy only. Patients with a low malignancy tumor (10/11) and adenoid cystic carcinoma (6/12) responded better than patients with a high malignancy carcinoma (2/12). A tumor larger than 4 cm, facial nerve palsy, lymph node metastasis, and inoperability indicate a poor prognosis. With high dose radiotherapy it is possible to treat inoperable tumors successfully. Adenoid cystic carcinomas can respond well to irradiation alone.